CT angiography for the assessment of EVAR complications: a pictorial review

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment proposed as an alternative to open repair in patients with abdominal aortic aneurysms. EVAR consists in a stent-graft placement within the aorta in order to exclude the aneurysm from arterial circulation and reduce the risk of rupture. Knowledge of the various types of devices is mandatory because some stents/grafts are more frequently associated with complications. CT angiography is the gold standard diagnostic technique for preprocedural planning and postprocedural surveillance. EVAR needs long-term follow-up due to the high rate of complications. Complications can be divided in endograft device-related and systemic complications. The purpose of this article is to review the CT imaging findings of EVAR complications and the key features for the diagnosis.

Recurrent cardiac hydatid cyst located near the root of the superior vena cava and the interatrial septum: a case report

Introduction: Cardiac localization of hydatid disease is rare (<3%) even in endemic countries. Affection characterized by a long functional tolerance and a large clinical and paraclinical polymorphism. Serious cardiac hydatitosis because of the risk of rupture requiring urgent surgery. The diagnosis is based on serology and echocardiography. The aim of this work is to show a case of recurrent cardiac hydatid cyst discovered incidentally during a facial paralysis assessment. Methods: We report the observation of a 26-year-old woman operated on in 2012 for pericardial hydatid cyst presenting a cardiac hydatid cyst located near the abutment of the SCV discovered incidentally during an exploration for left facial paralysis: NYHA stage II dyspnea. Chest x-ray: CTI at 0.48. ECG: RSR. Echocardiography: Image of cystic appearance at the level of the abutment of the SVC. SAPP: 38 mmhg, EF: 65%. Thoracic scan: 30/27 mm cardiac hydatid cyst bulging the lateral wall of the right atrium and the trunk of the right pulmonary artery with fissured cardiac hydatid cyst of the apical segment of the right lung of the right lower lobe with multiple bilateral intra parenchymal and sub pleural nodules. The patient was operated on under CPB. Intraoperative exploration: Presence of a hard and whitish mass, about 03 / 03cm developed in the full right atrial wall opposite the entrance to the superior vena cava. Procedure: Resection of the mass removing the roof of the LA, the AIS and the wall of the RA with reconstruction of the roof of the RA by patch in Dacron and reconstruction of the IAS and the wall of the RA by a single patch in Dacron. Results: The postoperative suites were simple. Conclusion: The hydatid cyst is still a real endemic in Algeria, the cardiac location is rare but serious and can constitute a real surgical emergency, hence the importance of prevention. Keywords: Hydatid cyst of the heart; Recurrence; Surgery; Cardiopulmonary Bypass; Prevention

Recurrent cardiac hydatid cysts ruptured intraoperatively during anesthetic induction for open-heart surgery

Introduction: Cardiac localization of hydatid disease is rare (<3%) even in endemic countries. Affection characterized by a long functional tolerance and a large clinical and paraclinical polymorphism. Serious cardiac hydatitosis because of the risk of rupture requiring urgent surgery. The diagnosis is based on serology and echocardiography. The aim of this work is to show one of the fatal complications of this condition which arose intraoperatively during anesthetic induction. Methods: We report the observation of a 37-year-old woman operated on in 2010 for a cardiac hydatid cyst presenting a recurrence of cardiac hydatid disease with two left intraauricular cysts expressed by palpitations with dyspnea. Preoperatively: dyspnea stage II of the NYHA. Chest x-ray: CTI at 0.58. ECG: RSR. Echocardiography: Two largest left atrial cysts: 47/40 mm compress the origin of the right pulmonary vein, 2nd cyst of 36/28 mm. The existence of another small caliber lateral cyst. Positive hydatid serology. The patient developed an anaphylactic shock of unexplained cause, which required the assistive CPB facility. Intraoperative exploration: The two ruptured cysts in the left atrium with multiple left intraatrial daughter vesicles. Gesture: Removal of daughter vesicles with sterilization with hypertonic saline. Results: The postoperative consequences were favorable despite a prolonged stay in intensive care following a picture of acute respiratory distress syndrome. Conclusion: Intracardiac rupture is a very serious complication and can produce dramatic pictures with sudden death. It can be responsible for allergic reaction, systemic embolism, pulmonary embolism and systemic metastases. Keywords: Hydatid Cyst; Heart; Relapsing; Rupture; Surgery; Anaphylactic Shock; Cardiopulmonary Bypass; Prevention

Carotid-Axillary Bypass and Debridement for a Mycotic Aneurysm of the Left Subclavian Artery

Mycotic subclavian aneurysms are rare, and their presence typically mandates urgent repair due to the associated high risk of rupture and mortality. A multi-disciplinary team effort is of utmost importance in ensuring favorable results. In this case report, we present a 79-year-old male with a rapidly enlarging mycotic left subclavian artery aneurysm secondary to a retrosternal abscess and left sternoclavicular septic arthritis, who underwent aneurysmal exclusion, a left carotid-left axillary bypass and pectoralis muscle flap coverage with a good outcome.

Clinical observation of a patient with hemangiomatosis involving skin, subcutaneous tissue, lung, stomach, intestinal, liver, kidney, spine

Aim. The work demonstrates a clinical case of an extremely rare pathology ‒ hemangiomatosis with damage to the skin, subcutaneous tissue, lungs, stomach, intestinal, liver, kidneys, and spine. Results. Patient L., born in 1994 with multiple hemangiomas. No heredity was observed for vascular tumors. In childhood, several large hemangiomas had to be surgically removed. She resorted to the Amur Regional Perinatal Center about her first pregnancy. There was a high risk of hemorrhagic complications due to damage to internal organs, primarily the lungs. Since there were multiple lesions of the vertebrae, it was decided not to use neuraxial methods of anesthesia. Total intravenous anesthesia and artificial ventilation of the lungs under the control of bronchoscopy were chosen by the method of anesthesia. Hemangiomatosis with lesions of internal organs was the indication for a Cesarean section. The operation took place without complications. The child was born healthy. Conclusion. In most cases, cosmetic defects are a significant problem of hemangiomatosis. However, in a number of situations, for example during pregnancy, there is a high risk of rupture of hemangiomas and the development of bleeding. In this case, the choice of the method of delivery and anesthesia depends on the location of the hemangiomas.

Unusual Intracranial Manifestation of Infective Endocarditis

Objective: The mycotic aneurysm is a rare intracranial pathology seen with pre-existing infective endocarditis. It has a high mortality rate due to its risk of rupture and needs early diagnosis and treatment. Methods: A 23-year male patient who presented with infective endocarditis subsequently developed a left parietal-temporal intracranial haemorrhage with suspicion of aneurysm after the course of antibiotic treatment as seen on Computed Tomography (CT) scan. Digital Subtraction Angiography (DSA) revealed a ruptured fusosaccular aneurysm in the distal parietal branches of the left Middle Cerebral Artery (MCA), for which glue embolization of the distal parent artery and aneurysm was done. Result: The interventional endovascular procedure was done with complete obliteration of the distal parent artery, mycotic aneurysm, and normal filling of the left internal cerebral artery (ICA) branches. Conclusion: Mycotic intracranial aneurysms (MIA) are a rare form of cerebrovascular pathology which needs early diagnosis with endovascular intervention when rupture occurs.

Circulating miR-126 as a Potential Non-invasive Biomarker for Intracranial Aneurysmal Rupture: A Pilot Study

Aim: Intracranial aneurysms (IAs) are characterized by abnormal dilation and thinning of the cerebral vessels wall, leading to rupture and life-threatening aneurysmal subarachnoid hemorrhage (aSAH) condition. This dictates the need to find new biomarkers that predict the presence of IAs and the risk of their rupture. The aim of this study was to measure circulating miR-126 at various time points post-aSAH to identify the timing of peak levels. Methods: Plasma samples from 62 patients with unruptured IAs (UIAs), 80 patients with aSAH at various time points (1, 3, 7, and 14 days post-event), and 47 healthy control were collected and subjected to qRT-PCR analyses for the expression levels of circulating miR-126. ROC curve and AUC were used to evaluate the diagnostic value of circulating miR-126. Results: The expression levels of circulating miR-126 were increased in patients with UIAs than in the healthy control. Furthermore, the expression levels of circulating miR-126 rose substantially from day 1 to day 7, but with a moderate decrease from day 7 to day 14 in plasma of patients with aSAH. The peak was observed on day 7. The AUC for miR-126 was 0.75, 0.75, 0.82, 0.87, and 0.79, respectively, and demonstrated that circulating miR-126 displayed considerable accuracy in discriminating plasma of patients with UIAs and patients after aSAH at various time points from a healthy control. Conclusion: Our results indicated that circulating miR-126 in plasma samples could be served as a potential non-invasive biomarker in IAs detection and prevention IAs with a high risk of rupture.

Comparison of embolization strategies for mixed plexiform and fistulous brain arteriovenous malformations: a computational model analysis of theoretical risks of nidus rupture

BackgroundHigh-flow fistulas related to plexiform nidi are found in 40% of large brain arteriovenous malformations (AVMs). Endovascular occlusion of intranidal fistulas before plexiform components is empirically considered safe, but potential ensuing dangerous re-routing of flow through plexiform vessels may in theory raise their rupture risk. It remains unclear whether it is safer to embolize plexiform or fistulous vessels initially. We used a novel biomathematical AVM model to compare theoretical hemodynamic changes and rupture risks on sequential embolizations of both types of nidus vessels.MethodsWe computationally modeled a theoretical AVM as an electrical circuit containing a nidus consisting of a massive stochastic network ensemble comprising 1000 vessels. We sampled and individually simulated 10 000 different nidus morphologies with a fistula angioarchitecturally isolated from its adjacent plexiform nidus. We used network analysis to calculate mean intravascular pressure (Pmean) and flow rate within each nidus vessel; and Monte Carlo analysis to assess overall risks of nidus rupture when simulating sequential occlusions of vessel types in all 10 000 nidi.ResultsWe consistently observed lower nidus rupture risks with initial fistula occlusion in different network morphologies. Intranidal fistula occlusion simultaneously reduced Pmean and flow rate within draining veins.ConclusionsInitial occlusion of AVM fistulas theoretically reduces downstream draining vessel hypertension and lowers the risk of rupture of an adjoining plexiform nidus component. This mitigates the theoretical concern that fistula occlusion may cause dangerous redistribution of hemodynamic forces into plexiform nidus vessels, and supports a clinical strategy favoring AVM fistula occlusion before plexiform nidus embolization.

Venous tortuosity as a novel biomarker of rupture risk in arteriovenous malformations: ARI score

BackgroundRisk of rupture in arteriovenous malformations (AVMs) varies considerably among series. Hemodynamic factors, especially within the venous side of the circuit, seem to be responsible but are not yet well defined. We analyzed tortuosity in the draining vein as a potential new marker of rupture in AVMs, and propose a simple index to predict AVM bleeding.MethodsA retrospective analysis of the venous angioarchitecture of brain AVMs was carried out at our center from 2013 to 2021, with special attention to venous tortuosity. After univariate analysis, the features of interest were combined to construct several predictive models using multivariate logistic regression. The best model proposed was the new AVM rupture index (ARI), which was then validated in an independent cohort.Results68 AVMs were included in the first step and 32 in the validation cohort. Venous tortuosity, expressed as at least one curve >180°, was a significant predictor of rupture (p=0.023). The proposed bleeding index consisted of: venous tortuosity (any curve of >180°), single draining vein, and paraventricular/infratentorial location. It seems to be a robust evaluation tool, with an area under the receiver operating characteristic (AUROC) curve of 0.806 (95% CI 0.714 to 0.899), consistently replicated in the independent sample (AUROC 0.759 (95% CI 0.607 to 0.911)), and with an inter-rater kappa coefficient of 0.81 .ConclusionsVenous tortuosity may serve as a predictor of bleeding in AVMs that warrants further investigation. This likely new marker was one of the three elements of the proposed ARI. ARI outperformed the predictive accuracy of previous scores, and remained consistent in an independent cohort.